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Medical Insurance Form
Medical Insurance Form
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TRAVEL INSURANCE INFO
Full Name written exactly as on passport
*
First
Last
Have you taken out Medical Travel Insurance for your current trip in South Africa
Yes
No
Please insure your Travel Insurance covers you for Riding Motorcycles over 300cc in a Foreign Country
Name of Travel Insurance Provider
Allergys Insurance Medical
Emergency Phone Number of Travel Insurance
Policy Reference Number
Please list any Medical problems or Allergys that you have
Please list any Medications that you are taking
Next of Kin Contact Information
Name of Next of Kin (Family or friend)
*
First
Last
Please give us the contact details of someone not on the tour with you.
Contact Number of Next of Kin
*
Relationship to you?
Comments:
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